Mid Staffs was a betrayal of the NHS

A memorial gallery of patients who died at Stafford hospital. Photograph: Christopher Furlong/Getty Images

I was horrified when I first heard about the appalling care at Mid Staffordshire NHS foundation trust nearly four years ago. The harrowing experiences of those affected were a betrayal of everything the NHS stands for. This week the resulting public inquiry, chaired by Robert Francis QC, is expected to deliver shock therapy to the healthcare system. His report will show how the NHS system and culture allowed the tragedy to happen, affecting hundreds of patients between 2005 and 2008. It will raise huge concerns about the management, quality assurance and regulation of the health service.

I passionately believe the NHS must seize this opportunity to rebuild public confidence and make the legacy of the tragedy a health service that is safer, more compassionate and consistently able to deliver high quality care. Such problems cannot be resolved by politicians, governments, regulators or anybody else. To be successful, the drive for change must be owned and led by those who run the service. NHS managers and clinicians must stand in front of the public and say: the buck stops here.

So what should happen? The key is to make the NHS more open and transparent by giving patients and the public more access to information, such as their own care records and comparative performance data. We also need to listen to patients. They tried to raise the alarm about poor care in Stafford hospital, but were ignored. Patients need to have a central role in how their NHS is run. Compassionate values must count for as much as technical skills when staff are recruited to the NHS and throughout their career. As importantly, staff have to feel they are able to challenge any poor practices. Surveys suggest that only 11% of doctors have confidence in current whistleblowing procedures. Open discussion of problems, backed by clear action, should be the norm in all NHS organisations.

The common purpose for all managers and clinicians should be improving the quality, experience and outcomes of care – in the past we have seen local and national organisations failing to act on reports of poor care because they thought someone else was responsible. Politicians and policymakers have a duty to support, not inhibit, this.

My fear for the inquiry is that it will trigger a blame game and a clamour from the public and politicians for excessive regulation, distracting structural change or unnecessary micro-management. It is too easy to conclude that government targets relating to waiting times or financial balance crowded out the ability to focus on basic standards. In reality, reducing waiting times saved lives. And achieving financial balance is a duty to the taxpayer. These are not alternatives to care and compassion. They could and should be managed in tandem - and in good NHS trusts they are.

The NHS has always struggled to resolve the tension between front-line autonomy, which encourages innovation, and the consistency delivered by central command-and-control management. We need to learn where we have got this balance wrong.

I certainly don't think we should ramp up the number of inspections. Inspections have their place, but they risk externalising responsibility for quality to a regulator and encouraging a tick-box culture. They may also give the public a false sense of assurance. Inspections will never identify all problems in a health system that sees a million people every 36 hours.

The government has suggested strengthening the accountability of NHS managers and I would welcome that, if it adds benefit, not just bureaucracy. Equally, steps to attract, reward and retain good NHS leaders would have a positive impact on patients.

The public and clinicians want leaders to be personally committed to an organisation, not merely making another career step. Like many of my colleagues, I have worked in the NHS for over 30 years because I want to help improve care, not just balance books.

The temptation for politicians responding to the report will be to play politics with the NHS again. But this must be about sustainable and effective solutions, not creating headlines and the impression of action. Mid Staffs is the NHS's problem. It is up to those working in the NHS to ensure it never happens again.